MRHA Rural Clinic Vaccine Survey

We are excited to introduce our new vaccine advocacy program and invite you to participate in an important survey that will help shape its development. Your insights and feedback are crucial in ensuring the success of this initiative, which aims to promote and facilitate vaccination efforts in our community. This brief survey will allow us to understand your needs, preferences, and challenges when it comes to enrolling in our program. Your input will enable us to tailor our services to best meet your requirements and enhance our collective impact. Please take a few moments to complete the survey, as your valuable input will greatly contribute to our shared goal of fostering a healthier and safer future for all. Please reach out to Alicia Edmonson alicia@morha.org or 573-418-0974 with any questions.
Full Name
Email
example@example.com
Organization
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Does your clinic offer and administer vaccines to the following populations?

Children (Birth – 18 years of age)Adults (19 years and older)No vaccines available at our clinic
If no vaccines are offered at your clinic please list any barriers to administering vaccines.
Please check which vaccines are available at your clinic.

DTapTdapPolioMeasles Mumps RuebellaCOVID - 19Type a questionHepatitis BHepatitis AHIBMeningococcal Conjugate VaccineMen BPPSV23PCV12/15PCV20ShinglesHPVRotavirusVaricella
Do you participate in the Vaccines for Children Program

YesNo
If you do not participate in Vaccines for Children Program please list any barriers to participation.
Are you enrolled with the state of Missouri as a COVID-19 vaccine provider?

YesNo
If no, please list barriers to participation.
Does your clinic utilize standing orders for vaccines?

YesNoFlu and PPSV23 and PCV20 only
Are your standing vaccination orders current?

YesNo
Does your clinic annually update immunizing staff on current recommendations?

YesNo
Do you submit immunizations administered to ShowMeVax (Missouri's Immunization Information System)?

YesNo
If no, please list reason.
Do you have a reminder/recall system to remind patients of the need for vaccinations?

YesNo
What resources would assist you in your vaccination program or administration?

Vaccine Storage UnitsStaff TrainingStaffingCommunity OutreachPolicy SupportOther
Please provide any additional information that may be helpful in supporting you and your facility.
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